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03/15/2005 11:29 5306756005 <br />03!15!2006 07:59 26546E <br />STRATUS NO CALIF <br />EHD <br />I_ }�I7 <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />�E�,E '"r E�ENVIRONMENTAL HEALTH DEPARTMENT (EHD <br />MAR 18 200 3104 E. Weber, Third Floor, Stockton, CA,, 95202 <br />(209) 468-3449 <br />PAGE 02/02 <br />PAGE 02 <br />S ITE <br />MITIGATION <br />UNIT IV <br />ENVONMENJ �[``��11(�rh�� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROMATE ISS <br />QU <br />Application Iw�`tC�� klaquin County for a permit to construct andbr In$t311 the work dsscrided- This application i; rnade In COfnpliar= with San <br />Joaquin County Development <br />�fTiitl�e+, Chapter 41115,3 and the Stnndardc of San Joaquin County Envlronmerrtal Health Department <br />kr/ <br />� eW4Llt AOI a0`JD •�Pin'or ) pp f i �q ASSeS&4r5 <br />WELL Location Crass Stmt �ytvrfil 5L pity Skk Zip S Z" ► Pam�l# <br />PROPERTY <br />Owner ti <br />t1_.,,,y 3� i <br />L Address as �V21?Y trY1J� 1� " Clty-_J_ l lrn ZPJS2hZPhone# alb J- 3 - t, <br />r <br />�. <br />�• <br />C-51Contractor ft <br />Mlim Addrees350 LLu,d 111 _CityC Ivi Zip alLic#4g51L5 Phone# 1 a L3-.SRoa*3 <br />FEE INFO <br />Ge�S�itdPilSuhCntr <br />J �D(Awi�n-�,-5 <br />�S ilbn +'Address 67 <br />Pr.i(a,4&6wrmf+�Cir `15lc8Z Phone 476- 0 <br />PERMIT! SERVICE REQUCST #i <br />_ <br />015 Cocrdinefes- X <br />Y Township Range Section <br />- <br />WORT TOELF RFORmr=D- <br />C <br />NEW WELL I BORING <br />(CPT, GEOP ROBE, HYOROPUNCH, HAND -AUGER, OTHER-) DUTRUCTION (choose type below) <br />SOIL BORING # OVER BORE. <br />Q <br />DIAMETER <br />F VELL# <br />u)--13 fu -1!f 0 PRESSURE GROUT <br />p'Other <br />SPECIFICATIONS_ <br />GROUT <br />*-I <br />9-3 <br />COMMENTS: -1 <br />;1A5j'A/. �1'1Lu-1�{ in jolig;,p MW- dr��p G wi+,yt, IG -0 ;,I <br />C) <br />j lipl� <br />ON <br />TYPE OF WELL <br />INSTAI,LAT]ON_TYPE CONSTRUCTION SPECIFiCAT10NS <br />MONITORING <br />HOLLOW STr!m DIA. OF BORI"HdLE - MULTIPLE,CASINGS (] MULTI-LEVEL CASING DLA' <br />(] EXTRACTION <br />THER <br />p AIR HAMMEPf0RIVEN CASING THICKNESS TYF'E OF CASING: a STEEL )�PVG 0 OTHER-- <br />0 VAPOR <br />0 <br />D MUD ROTARY DEPTH OF GROUT SEAL TREMIE -YFE 70 BE USED- D AUGERS 11 HOSE <br />0 AIR SPARGE/ DONE j] PUSH POINT (GP cr CPT)GROUTSEAL PUMPED: Was No (NOTE: MAXIMUM FR E -FALL DEPTH IS 30') <br />p SOIL BORING <br />�Q <br />0 HAND AUGER GROUT SPSCIFICA70NS AOI - <br />0 0THEIR ii OTHER APPROX- BORING DEPTH JQ�- 12d Q BOLTED TRAFFIC BOX 1] STOVE PIPE <br />�S CONDUCTOR CASING PROPOSED 40 (iF YES, list specifications in comment Section) <br />l �t iii �S�c% c?�-�t,`LZ wl 4r� I�a.ri5 f c�ia�cl� Sc�,?f Wi LaN"UC , <br />MOTE: OFFSITE BORINGS REQUIRE ACCESS AGREO-mrn(T OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS, <br />I hereby certify that 1 have prepared this application and that the Work will be done in accordance with San Joaquin <br />County Ordinances, R e and Regulations, and all applicable California State Laws, <br />Signed x .54 <br />Tide/Company7 ey �o� i S� ~ 5 1 %aNS FAOrovi t .T�t� <br />Print N2me ._ J C. c 1 �ti IMAM Daze <br />M461IN WA <br />SITE MAP IN UNIT IV FILE, ADPRESS' 2-c35-0 <br />WORK PLAN DATED,' 10 I I_ I D 7 <br />Application Accepted By (A �t c o-- Date Issue 3 ! O Area <br />GrDUt Inspection Sy Via -inn .C.A Date O Final Inspection 6y c� �/L /0( <br />Destruetign Inspgctian By Date <br />COMMENTS f CONDITIONS: <br />ONLY: <br />AIU, <br />FAC# <br />c C(� C <br />EACCOUN71NG <br />ES <br />FEE INFO <br />AMOUNT REMITTED CHECK # <br />REC'Q BY <br />DATE <br />PERMIT! SERVICE REQUCST #i <br />INVOICE <br />3s�3 {Z ,,c2c <br />